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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOF 0 FICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> w APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. �a <br /> THIS .PERMIT EXPIRES 1 YEAR FROM DATE ,ISSUED Date Issued <br /> Y (Complete In Triplicate) <br /> Application is hereby made to'!, the ,San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaqui <br /> County Ordinance No. 1$62 and{-.the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION N, p CENSUS TRACT <br /> i --- <br /> Owner's Name '--'A" 9''� Phone <br /> Address i �•-= City <br /> Contractor's 'Name 1 License # �yPhone � <br /> TYPE OF WORK (Check) .' i NEW,:WELL / / DEEPEN / / RECONDITION / / ' DESTRUCTION <br /> PUMP INSTALLATION / / , PUMP REPAIR / PUMP REPLACEMENT /_ <br /> ,.Other <br /> DISTANCE TO NEAREST: `SEPTIC TANK SEWER LINES PIT PRIVY <br /> ,r , <br /> 'SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial I Cable Tool Dia. of Well Excavation <br /> Domestic/private; I. Drilled Dia, of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> >., Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal I Other Other Information <br /> Geophysical \� <br /> Surface Seal Installed By: `1 <br /> � <br /> ` PUMP INSTALLATION: Contractor <br /> Type of Pump H.P, i. Or LL► <br /> PUMP REPLACEMENT: / / state Work Done <br /> PUMP .REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply withl'all laws and regulations of the San Joaquin, Local Health District <br /> ` and the State of California pertaining to or regulating well -construction. Within FIFTEEN DAYS <br /> after completion- of my! work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the- well in use. The above <br /> information is true to` the best knowle •ge and elief. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO G NG AND A FINAL ',IN` CTID <br /> at <br /> SIGNED ITLE <br /> IM (D W PL AN ON R RSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS: �� <br /> - 1,? - <br /> PHASE II GROUT INSPECTION. PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE Z ! <br /> b/77 <br /> E H 1426 Rev., 1-74 _ 2 <br />